SEATTLE, Jan. 9, 2003 — In conflict after conflict, whenever one of its most deadly enemies rears its head, the U.S. military employs a potent weapon: a little orange pill. The enemy is fatigue, a foe that claimed more deaths among military pilots in the past two decades than combat duty. The solution is selective use of amphetamines, an effective stimulant that has kept military aviators fierce-eyed and alert from the Battle of Britain to night strikes over Afghanistan. With air wings deploying again to the Persian Gulf, questions are surfacing about the safety of “go pills” in the cockpit.

Fatigue has been inherent to battle since the Spartans fell to Xerxes’ Persians at Thermopylae, and while war itself has changed, fatigue remains a constant. The modern cockpit is a case in point: flight crews face a dizzying mix of routine tasks and quick decision-making, all while controlling an intricate machine bristling with lethal weaponry. Add missions stretching thousands of miles, the stress of combat and enemy fire, and fatigue can be deadly.

The Air Force alone has recorded nearly 100 fatal crashes due to pilot fatigue, one reason the surgeons general of the various branches of the armed forces have been open to new ways to keep flight crews well rested and alert.

U.S. military management of fatigue is more nuanced and cautious than ever. Squadron commanders work closely with flight surgeons to make sure pilots are fit to fly. Successive conflicts dominated by air power — the Gulf War in 1990-91, Kosovo in 1999 and last year’s Afghan campaign — raised awareness of the physical demands and risks of flying at night and on long missions.

Alert or impaired?
The use of drugs to address the problem — a practice that goes back decades — is now under fire. Earlier this month, two Air National Guard pilots who mistakenly bombed Canadian troops during an F-16 flight over Afghanistan last year, claimed the “go pills” they took before the mission impaired their judgment. Lawyers for the two airmen, Maj. Harry Schmidt and Maj. William Umbach, contend the military pressured their clients to take the go pills — as the prescription amphetamine Dexedrine is called in the military.

Amphetamine use to battle cockpit fatigue has been proven effective. Considered a Schedule II substance by the federal government, its impact on neurotransmitters increases consciousness and can help stabilize sleep patterns. What’s less clear is the impact of its side effects: elevated blood pressure and heart rate, nervousness and restlessness.

Moreover, flight surgeons and pilots are faced with the reality that they’re using a highly addictive substance — one that reportedly hooked some pilots during the Gulf War with its ability to help them perform and change their sleeping cycles for night missions.

By contrast, civil pilots are expressly banned from using anything stronger than caffeine to stay awake. Federal aviation regulations specify amphetamines as a substance with potential for abuse, and its presence in the blood is checked during both routine pilot drug tests and forensic exams after fatal accidents.

Apples and oranges?
But military doctors argue their pilots confront a host of tricky medical challenges that civilian pilots — even long-haul airline pilots — never face: grueling, tricky missions without backup crews and cramped cockpits that all but immobilize a pilot.

Dr. Russell B. Rayman, executive director of the Aerospace Medical Association and a 25-year veteran pilot and flight surgeon for the Air Force, says you simply can’t compare the experience of long-haul civilian passenger jet pilots with those flying high-performance warplanes over hostile territory.

“When you’re strapped in an A-10 and flying hour after hour,” he says, “it’s very different.”

Even the military has had cause for concern about go pills and counteracting “no-go pills” — prescription sedatives used to help pilots sleep after an extended mission and go-pill use.

Though Air Force officials insist there is “no documentation of any pilot in the Gulf War being adversely affected” by amphetamine use, flight surgeons found some pilots were exceeding their generally small dosage of the pills during the 1991 battle with Iraq and regularly using the pills as part of their flight regimen.

Military officials suspended the go-pill program in 1992 after the war was over, though the Air Force insists the reasoning was that combat had ended and pilots’ missions returned to a more normal bent. The Air Force’s use of pills was reinstated in 1996, with strict protocols, as U.S. pilots began regular bombing runs over the Balkans. Those missions, usually at night, required crews to travel hundreds or thousands of miles to reach their targets.

“What happened was, almost immediately, crews started complaining as sorties started growing in duration,” says Col. Peter Demitry, a fighter pilot and assistant deputy surgeon general for the Air Force who helped craft its current policy. “With the long, almost draconian bomber mission durations, we were forced to go back and review medical science.”

Pill counts
The current program is strictly regulated — and wholly voluntary for pilots who opt in. They’re first tested on the ground for any adverse effects and must sign a consent form that emphasizes use is a voluntary decision and requires them to acknowledge that “the U.S. Food and Drug Administration has not approved the use of Dexedrine to manage fatigue.”

Pills are handed out by flight surgeons just before and remainders collected after a flight, with each one meticulously recorded on a sheet — although some officers insist pilots need the flexibility to manage their own sleep schedules and routine and have resisted a standard regimen for pill usage. Critics see it as the military forking over pills to pilots; military doctors insist it’s a crucial tool to battle what could otherwise be a deadly factor during a 30-hour mission.

“The pilot and the pilot alone in the privacy of his cockpit, in a life-and-death situation, decides whether he should swallow this insurance policy,” says Demitry. “I have not had the personal need to use them, but I was glad they were available.”

The pills’ current use has largely been prompted by commanding officers looking to improve their squadrons’ abilities and keep their crews safe. Requests must go through a flight surgeon, who reviews the specific goals of a mission and sets out a plan for usage.

Subtle pressures?
But some commanders have insisted all their pilots have the pills on hand as a precaution; it may not be a mandate to use them, but some critics — such as the lawyers for the two F-16 pilots in the Afghan friendly fire incident — suggest it amounts to significant pressure from a superior officer.

Standard dosage is 5 to 10 mg, similar to what might be used to help treat a child’s hyperactive disorder and less than prescribed for most adult sleep disorders. Doctors suggest pilots take no more than one every four hours, and even with side effects the military dosage is negligible, according to several doctors and pharmacologists.

Still, studies of Japanese pilots during World War II — who also used amphetamines — showed high potential for abuse, especially because of the dependent use of the drug to accomplish a professional task.

“It’s not that any pilot that takes amphetamines is going to get addicted,” says University of Michigan pharmacology professor Margaret Gnegy. “It’s what’s in their minds when they take the drugs. People can become addicted after very small doses.”

Go, no-go
As if the body chemistry weren’t already complex enough, for pilots who can’t sleep after finishing a mission, officials have added a second component to the program: the “no-go pill,” prescription sedatives such as Ambien or Restoril used to let pilots rest after mission use of the go pill. Again, officials insist the no-go pills are essential in maintaining normal sleep patterns for crews who often are working under conditions that defy the body’s desire for rest and normal circadian rhythms — whether it applies to military or civilian pilots.

“The ones that are having their brains on an old time zone going into a new time zone, they’re going to be impaired. During biological night, they’re going to be sleepy and impaired,” says Dr. Virgil Wooten, medical director of TriHealth Sleep and Alertness Centers and an FAA medical examiner and sleep consultant. “If I were in the back of a plane going across to Asia, I would feel better knowing they were up there with access to Dexedrine.”

Still, extended flight missions have been routine for decades in the armed forces — usually without the benefit of the pills. Navy aviators, for example, only began using Dexedrine in November of last year, well into the Afghan campaign. (Navy doctors approved a go-pill program in 2000.)

“Our standard mission was 10-12 hours and there was never any suggestion that we take anything,” says retired Navy Capt. Charles “Chuck” Sipe, who flew Cold War patrol missions in a P-3 Orion and now teaches at the Naval War College. “If you’re too tired to fly, you don’t take a pill to boost your endurance. It’s a bad idea.”

But on the whole, most commanders and their pilots laugh off the concerns as rather trivial given the life-and-death realities of combat. Though current go-pill guidelines are firmly regimented, officers are reluctant to set strict mandates on pilots whose role is largely to make subjective decisions so they can accomplish concrete goals. As one Gulf War commander suggested in describing his endorsement of go pills, “If you can’t trust them with the medication, then you can’t trust them with a $50 million airplane to try and go kill someone.”